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144 �1- U 10 <br /> UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK)!CONTAMINATION SITE REPORT <br /> EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES FOR LOCAL AGENCY USE ONLY <br /> REPORT BEEN FILED? I HEREBY CERTIFYTHAT I HAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br /> ❑ VES NO E:] YES NO <br /> '.DISTRIBUTION SHOWN ON THE INSTRUCTION SHE ON THE BACK PAGE OF THIS FORM <br /> REPORT DATE (� CASE* J <br /> v u `"F Y SIGN DATE <br /> NAME OF INDIVIDUAL FILING REPORT PHONE RE <br /> y o i $_a <br /> w REPRESENTING ❑ OWNER/OPERATOR ❑ REGIONAL BOARD COMPANY OR AGENCY NAME <br /> S LOCAL AGENCY ❑ OTHER '?OS- <br /> ADDRESS 9szo2 <br /> �A -I IIP <br /> w NAAM((E�� � � CONTACTPERSON PHONE <br /> ^ <br /> Z <br /> � vxck-, ❑ UNKNOWN <br /> a " p C 9o8 cr4 4go3c� <br /> STREET cm STATE vp <br /> FACILITY NAME(IF APPLICABLE) OPERATOR PHONE <br /> Gid c (Cubby- �9> 83s�4 <br /> a ADDRES <br /> S <br /> I STREET , C COUap <br /> m CROSS STREET <br /> W LPIV V^ ,b AGENCY NAME CONTACTPERSON PHONE <br /> w <br /> REGIONAL BOARD PHONE <br /> 3 CV <br /> y (7) NAME QUANTITY LOST(GALUO <br /> wQ ` UNKNOWN <br /> r <br /> N <br /> ❑ UNKNOWN <br /> Q DISCOVERED �c� Y� HOW❑DISCOVKTEST E::] TANKERED O OVAL CONTROL O SOTMERRFACE MONITORING ❑ NUISANCE CONDITIONS <br /> Ew! <br /> m DATE DISCHARGE BEGAN METHOD USED TO STOP DISCHARGE(CHECK ALL THAT APPLY) <br /> UNKNOWN ❑REMOVE CONTENTS,Iy1CLOSE TANK&REMOVE ❑REPAIR PIPING <br /> Y C Y Y <br /> HAS DISCHARGE BEEN STOPPED? ❑REPAIR TANK ❑CLOSE TANK&FILL IN PLACE ❑CHANGE PROCEDURE <br /> Wo YES ❑ NO IFYES,DATE R lY Y ❑REPLACE TANK ❑OTHER <br /> SOURCE OF DISCHARGE �I CAUSE(S) <br /> a ❑ TANK LEAK IJL UNKNOWN OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br /> w ❑ PIPING LEAK r❑s OTHER ❑ CORROSION UNKNOWN ❑ OTHER <br /> w CHECKONEONLY <br /> ❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER -(CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN AFFECTED) <br /> CHECK ONE ONLY <br /> w ❑ NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED ❑ POLLUTION CHARACTERIZATION <br /> m ❑ LEAK BEING CONFIRMED ❑ PRELIMINARY SITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRESS <br /> O ❑ REMEDIATION PLAN ❑ CASE CLOSED(CLEANUP COMPLETED OR UNNECESSARY) ❑ CLEANUPUNDERWAY <br /> CHECK APPROPRIATE ACTION(S) ❑ EXCAVATE&DISPOSE(ED) ❑ REMOVE FREE PRODUCT(FP) ❑ ENHANCED BIO DEGRADATION(R) <br /> Isg smR raROET.usI <br /> o ❑ CAP SITE(CO) ❑ EXCAVATE&TREAT(ET) ❑ PUMP&TREAT GROUNDWATER(GT)❑ REPLACE SUPPLY(RS) <br /> w� <br /> w< ❑ CONTAINMENT BARRIER(CB) ❑ NO ACTION REQUIRED(NA) ❑ TREATMENT AT HOOKUP(HU) ❑ VENT SOIL(VS) <br /> ❑ VACUUM EXTRACT(VE) ❑ <br /> OTHER(OT) <br /> uv#��cli SY �c VVLC , ' nLAJ r.X �uL vnc <br /> c7T ca.4(-QyKkKa-Arno ass "u/er4a( <br /> by �- . <br /> Nsc tS IS9A <br />